TotalABA Clinical Documentationinviscidsoftware.com/trainingVids/Manuals/TotalABA... · plan templates. The following fields/sections are available on the template: Template Name

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TotalABA Clinical Documentation

Contents Summary ....................................................................................................................................................... 2

Security ......................................................................................................................................................... 2

Initial Setup ................................................................................................................................................... 2

Customization ........................................................................................................................................... 3

Assessments .................................................................................................................................................. 3

Lesson Categories ......................................................................................................................................... 3

Lesson Plan Templates .................................................................................................................................. 3

Lesson Plans .................................................................................................................................................. 5

Lessons .......................................................................................................................................................... 7

Creating/Modify a Lesson ......................................................................................................................... 7

Perform Lesson ......................................................................................................................................... 7

Lesson Observation Data Collection Left Pane ..................................................................................... 8

Switching Between Lessons .................................................................................................................. 8

Data Collection Settings ........................................................................................................................ 8

Bulk Observations ..................................................................................................................................... 9

Quick Lesson ............................................................................................................................................. 9

Viewing a Lesson ....................................................................................................................................... 9

Lesson Results Page .................................................................................................................................. 9

Therapy Types ............................................................................................................................................... 9

Treatment Plans ............................................................................................................................................ 9

Treatment Goals ..................................................................................................................................... 10

Add Multiple Treatment Goals ........................................................................................................... 10

Treatment Goal Responses ................................................................................................................. 10

Recalculating Treatment Goal Data .................................................................................................... 11

General Recommendations .................................................................................................................... 11

Therapy Recommendations .................................................................................................................... 11

Examples ..................................................................................................................................................... 12

Lesson Categories/Plans ......................................................................................................................... 12



Compact versus Expanded Layout .......................................................................................................... 13

Summary The clinical portion of TotalABA currently consists of the following tabs: Assessments, Lesson Categories,

Lesson Plans and Treatment Plans. Each one is described in further detail below. These pieces have

been added in order to help your practice maintain, document, and analyze your student’s history and

progress.

Security There are three different security permissions that may be granted to the users in the practice. If none

of these are assigned, then the user will not have any access to the clinical records. If needed,

customized security can be added to your practice, just let us know.

1. Clinical Administrate – Ability to create/modify/view lesson categories, lesson sub-categories

and lesson plans. Additionally, can create/modify/view all assessments, Lessons and Treatment

Plans.

2. Clinical Modify - Ability to create/modify/view all assessments, lessons and treatment plans.

Can view lesson categories, lesson sub-categories and lesson plans.

3. Clinical View - Ability to view all records in the clinical portion (assessments, lesson categories,

lesson sub-categories, lesson plans, lessons and treatment pans).

Initial Setup Your practice will be required to setup the clinical information before it data can actually be collected

for the students. Go to the Clinical Setup tab to access these items. This includes the following record

types:

Therapy Types – This is used to setup the different therapy disciplines performed by your

practice. By default, ABA, Occupational and Speech will already exist.

Lesson Categories and Subcategories – These are used to organize the lesson plans in your

practice and will help locate the lesson plans when adding them to a treatment plan and/or a

session.

Lesson Plan Templates – This enables your practice to create templates for new lesson plans,

including the prompts and responses. While the templates are not required they will help save

time and potential mistakes. An ABA Trial Run template is automatically created for your

practice with four prompts (Independent, Gestural, Verbal and Physical) and one response

(Correct – yes/no).

Lesson Plans – Lesson plans are used to record and monitor various data for the students over

time.



Each of these sections are described in detail below.

Customization Many areas of TotalABA may be customized included security, fields, reports, etc. Please contact us if

any customization in your TotalABA site is desired.

Assessments The assessment record allows your practice to document an evaluation of the student’s current skill

level. When an assessment is initially created, the type of assessment must be selected. The options

are Initial Assessment and Reassessment. The reassessment contains additional fields that are not

available on the initial assessment.

The assessment may be created from the Student or an existing Session. If it is created from a Session, it

will be linked to both that session and student records.

An assessment may be signed-off by a user in the practice that has the Sign-Off permission. Once it has

been signed off, the following occurs.

1. The sign-off user and date fields are populated.

2. The assessment may no longer be modified. However, Notes & Attachments may still be

created.

Lesson Categories Lesson categories are used to organize Lesson Plans at the highest level. Go to the Clinical Setup tab to

access lesson categories. Examples of a lesson category are: Activities of Daily Living, School Skill. From

the lesson category, subcategories are created for further classification of the lesson plans. Examples of

a subcategory for Activities of Daily Living are: Prepare Shower and Test Water.

Lesson Plan Templates Lesson plan templates are used to quickly create new lesson plans using the predefined settings.

Selecting a lesson plan template when creating a new lesson plan will populate all of the information on

the plan from the template. This is extremely useful when you have a lot of lesson plans to create that

share the same settings/values. Note that lesson plan templates are only used for new lesson plans.

Changes to a template will not affect existing lesson plans. Go to the Clinical Setup tab to access lesson

plan templates. The following fields/sections are available on the template:

Template Name – Enter the name of the template (e.g. ABA Trial Run).

Active – Indicates if the template may still be used to create new lesson plans.

Therapy Type – Select the type of therapy for the lesson plan. The therapy types are created

and maintained by your practice and are used to organize the lesson plans.

Lesson Category – This is the category that new lesson plans will be part of.



Lesson Subcategory – This is the subcategory that new lesson plans will be part of.

Additional Details – Enter any additional details regarding the lesson plan. This will be displayed

in the Lesson Information section when performing the lesson and are useful to include any

instructions, etc.

Layout Type – Select the default layout type that is used when performing the lesson. This field

is required. The values are below and a picture of both is available in the Examples section of

this document.

o Compact - This displays each lesson plan response on a single line and does not use

icons. It is typically used when the lesson plan has several to many lesson plan

responses.

o Expanded – Uses icons where appropriate (e.g. yes/no response, prompts, and protest)

and is useful when there is only one or two responses available on the lesson plan.

Target Observations – The ideal number of observations that should be collected per lesson.

Include Protest Section – If checked, then the “Did the Student Protest?” section (yes/no) will

be available when performing a lesson.

Require Protest Selection – If checked, the student protest (yes/no) must be selected when

performing a lesson. This must be unchecked if Include Protest Section is not selected.

Require Prompt Selection – If checked, then a prompt must be selected when performing a

lesson. This must be unchecked if there have not been any prompts added.

Prompts – Used to record what induced the student to make their response. Examples include

(independent, gestural, verbal, etc.). Click the Add New button to create a new prompt on the

template and use the Up/Down links to reorder the prompts as they should appear when

performing a lesson.

o Name – This is the full name of the prompt. It will be displayed when entering lesson

observations unless a short name is entered.

o Short Name – An optional, abbreviated named for the prompt which will be used when

entering lesson observations and may also be used in reports.

Responses – Used to record the student’s answers, reactions, etc. Multiple responses of varying

data types may be recorded. Click the Add New button to create a new response on the

template and use the Up/Down links to reorder the responses as they should appear when


o Name – This is the full name of the response. It will be displayed when entering lesson


o Short Name – An optional, abbreviated named for the response which will be used

when entering lesson observations and may also be used in reports.

o Response Type – Indicates the type of data to be collected for the response. Select

from the following values.

Yes/No – Used to indicate if a correct response was made. In the expanded

layout, Yes and No icons will be available. In the compact layout, this will be a

checkbox. This type supports a % correct of the observations for reporting

purposes.



1-10 Scale – A value from one to ten may be recorded. A slider bar and a drop

down list are both available to record the value. This type supports an average,

high and low value of all the observations for reporting purposes.

Scoring % - A value from one to one hundred may be recorded. A slider bar and

a data input field are both available to record the value. This type supports an

average, high and low value of all the observations for reporting purposes.

Numeric – Any numeric value may be recorded in a data input field. This type

supports an average, high and low value of all the observations for reporting

purposes.

Free Text – Text may be entered in a multi-line field.

Picklist – A list of possible values are available via a drop down field. These

values are defined in the Picklist Values field.

o Picklist Values – This is only available when the response type equals “Picklist”. Enter

the values that should be available, separate each value by a new line.

o Required - Indicates if the response must have data entered/selected in order to save

an observation. Typically this is checked if there is only one response on the lesson

plan.

o Help Text – Optional text that is displayed when entering lesson observations (user will

hover over the help icon next to the name/short name).

Lesson Plans The lesson plan is used to setup the various programs that the students will be undertaking. Go to the

Clinical Setup tab to access lesson plans. Once lesson observations have been recorded for a given

lesson plan, the prompts and responses on the plan cannot be changed. If needed deactivate the lesson

plan and create a new one. A lesson plan consists of the following fields.

Lesson Plan Name – The name of the lesson plan.

Therapy Type – Select the type of therapy for the lesson plan. The therapy types are created

and maintained by your practice and are used to organize the lesson plans.

Active – Indicates if the lesson plan may still be used in sessions and treatment goals.

Lesson Plan Template – Select an existing lesson plan template to apply all the settings, prompts

and responses from the template to the lesson plan. This will help speed up the process of

creating new lesson plans and help eliminate errors.

Lesson Category – Select the category the plan belongs to.

Lesson Subcategory – Select the subcategory for the plan.

Additional Details – Enter any additional details regarding the lesson plan. This will be displayed

in the Lesson Information section when performing the lesson and are useful to include any

instructions, etc.

Layout Type – Select the default layout type that is used when performing the lesson. This field

is required. The values are below and a picture of both is available in the Examples section of

this document.



o Compact - This displays each lesson plan response on a single line and does not use

icons. It is typically used when the lesson plan has several to many lesson plan

responses.

o Expanded – Uses icons where appropriate (e.g. yes/no response, prompts, and protest)

and is useful when there is only one or two responses available on the lesson plan.

Target Observations – The ideal number of observations that should be collected per lesson.

Include Protest Section – If checked, then the “Did the Student Protest?” section (yes/no) will

be available when performing a lesson.

Require Protest Selection – If checked, the student protest (yes/no) must be selected when

performing a lesson. This must be unchecked if Include Protest Section is not selected.

Require Prompt Selection – If checked, then a prompt must be selected when performing a

lesson. This must be unchecked if there have not been any prompts added.

Prompts – Used to record what induced the student to make their response. Examples include

(independent, gestural, verbal, etc.). Click the Add New button to create a new prompt on the

template and use the Up/Down links to reorder the prompts as they should appear when


o Name – This is the full name of the prompt. It will be displayed when entering lesson


o Short Name – An optional, abbreviated named for the prompt which will be used when

entering lesson observations and may also be used in reports.

Responses – Used to record the student’s answers, reactions, etc. Multiple responses of varying

data types may be recorded. Click the Add New button to create a new response on the

template and use the Up/Down links to reorder the responses as they should appear when


o Name – This is the full name of the response. It will be displayed when entering lesson


o Short Name – An optional, abbreviated named for the response which will be used

when entering lesson observations and may also be used in reports.

o Response Type – Indicates the type of data to be collected for the response. Select

from the following values.

Yes/No – Used to indicate if a correct response was made. In the expanded

layout, Yes and No icons will be available. In the compact layout, this will be a

checkbox. This type supports a % correct of the observations for reporting

purposes.

1-10 Scale – A value from one to ten may be recorded. A slider bar and a drop

down list are both available to record the value. This type supports an average,

high and low value of all the observations for reporting purposes.

Scoring % - A value from one to one hundred may be recorded. A slider bar and

a data input field are both available to record the value. This type supports an

average, high and low value of all the observations for reporting purposes.



Numeric – Any numeric value may be recorded in a data input field. This type

supports an average, high and low value of all the observations for reporting

purposes. In the expanded layout, icons will be available to increment the value

by 1 in either direction.

Free Text – Text may be entered in a multi-line field.

Picklist – A list of possible values are available via a drop down field. These

values are defined in the Picklist Values field.

o Picklist Values – This is only available when the response type equals “Picklist”. Enter

the values that should be available, separate each value by a new line.

o Required - Indicates if the response must have data entered/selected in order to save

an observation. Typically this is checked if there is only one response on the lesson

plan.

o Help Text – Optional text that is displayed when entering lesson observations (user will

hover over the help icon next to the name/short name).

Lessons

Creating/Modify a Lesson Lessons are created, modified and attached to a session. To create a new lesson, open the session and

click on the New Lesson button in the lessons related records section. This section also lists any existing

lessons for the session. The following fields are available when creating/modifying a lesson.

Lesson Plan – Select the lesson plan that should be attached to the session. If a treatment plan

is already part of the session and that treatment plan has one or more treatment goals, then

only those treatment goals will be available for selection.

Start Date/Time – The date and time of the lesson. It will default to the current date and time.

Use as Baseline – Check this box if the lesson plan is part of a treatment goal and the

observations should be used in the baseline calculations for the treatment goal. If more than

one lesson has this selected, then the most recent lesson based on the Start Date/Time will be

used.

Perform Lesson Performing a lesson allows the therapist to record the student’s response(s) and additional information

for the lesson based on the corresponding lesson plan. Once an observation is saved, the therapist will

be able to record the next observation or cancel performing the lesson.

Click the Stop Lesson icon to end the recording of the observation for the current lesson. The existing

observation will not be saved. Note that additional observations may still be recorded for the lesson at

a later time.

Click the Clear Values icon to remove any selected for the Response, Prompt Level and Protest.



A summary of the prior observations is displayed while recording new observations (see the Lesson

Responses section above the New Observations).

Lesson Observation Data Collection Left Pane

The left pane displays all treatment goals if the session has been linked to a treatment plan.

Furthermore, it also shows any other lessons performed on the same date of service as the current

session, regardless of the treatment plan. Hovering over one of the lessons will display applicable

information and clicking on the icon at the end of the lesson (only appears if at least one observation

has been collected) will open the Lesson Results page for the lesson in a new window.

Click on the Change Settings button at the top of the left pane when performing a lesson to make

personalized settings for your user account. Click the View Legend button to view the various details of

the left pane.

Switching Between Lessons

Various lessons plans may be quickly recorded while entering new observations. In the left pane there is

a Quick New Lesson option that allows the user to select a new plan and start performing observations

immediately.

Furthermore, if the session has a treatment plan selected, then all corresponding treatment goals will be

listed on the left and may be clicked to perform that lesson.

Data Collection Settings

Click on the Change Settings button in the lesson observation left pane to access the data collection

settings for your user account. The following settings are available.

Left Pane Percentage – This controls the width of the lesson observation left pane relative to

the screen size. Enter a percentage between 10 and 40 to customize the display. A value of 18

to 20 is recommended as a starting point.

Display Lessons with Zero Observations – If checked, then lessons that have been created but

do not have any observations recorded will be displayed in the lesson observation left pane.

Lesson Results Icon Color Rule – Controls the icon that is displayed after each lesson in the left

pane. Clicking on the icon will open the lesson results page in a new window, regardless of the

rule.

o —None— A solid green icon will display at the end of each lesson that has at least one

observation.

o Show Red if Negative Yes/No Response – If selected, any lesson that has at least one No

response will have a red icon with an “x” in the center. Any lesson that has a response

type of yes/no but does not have any No responses will have a green icon with a “√” in

the center. Lessons that do not have a yes/no response type will have a sold green icon.

Display Info/Results Link – If checked, in the lesson observation left pan there will be a “Lesson

Results” link after the results icon and an “Additional Info” link after treatment goals without

any current lessons. This may be helpful for users working on a tablet/cell phone where the

hover option is not supported..



Bulk Observations Bulk observations allow the therapist to quickly add multiple observations that share all of the same

values to a lesson without performing the lesson for each individual observation. They will also be

flagged as bulk observations when viewing the lesson.

Furthermore, bulk observations may be deleted individually, or all bulk observations for the given lesson

may be deleted at once. Note: if bulk observations are deleted, then all of them regardless of their

values will be deleted for the lesson.

Quick Lesson Quick lesson can be used on sessions that have a treatment plan. It is also available from an existing

lesson, letting the user quickly transition from one lesson to another. It allows the therapist to create

the lesson and move directly into the observations with a minimal number of steps.

Viewing a Lesson An existing lesson may be opened from a session or a treatment goal. A summary of all the observations

will be displayed along with all the individual observations. Opening an individual observation will show

all of the responses that were recorded along with the prompt level and student protest if applicable.

Lesson Results Page The lesson results page is accessed from the left pane when performing observations or by clicking the

Lesson Results button when viewing a lesson. This page shows summary details for the

lesson/treatment goal along with all of the observations that have been recorded. For each observation

it shows the date/time it was recorded along with the prompt level (if applicable) if the student

protested (if applicable) and the value for each response for the lesson plan.

Therapy Types Therapy types are used to setup the various disciplines performed by the practice. They help

differentiate and organize the various lesson plans in the practice.

Treatment Plans A treatment plan has many of the same fields as an assessment. The difference is that a treatment plan

is used to determine what steps should be followed for that student moving forward. Furthermore, the

treatment plan contains extra details for recording the student’s progress for the record goals along

with any recommendations for treating the student.

The treatment plan may be created from the student record or from an assessment. If created from an

assessment, then the shared field types on the treatment plan (e.g. Assessment of Current Functioning)

will default to the value from the assessment.

If a student has only one active treatment plan, then it will be automatically selected on all new

sessions.


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Only active treatment plans may be used on a session.

Treatment Goals The Treatment goals section will allow a user to create one or more lessons plans that will be linked to

the treatment plan. Even though a student may have performed the same lesson plan multiple times,

each treatment goal will be one line item on the treatment plan with the following fields.

Objective – This is the name of the lesson plan and is a picker that allows the user to select an

active Lesson Plan.

Goal Details – Used to specify how the lesson plan should be specifically implemented for the

treatment plan and may be viewed from the lesson

Baseline Date – This is the date of the most recent lesson where Use as Baseline is checked.

Average Level - This is the % Correct average for all corresponding Lessons where the Treatment

Plan is linked.

Current Level Date - This is the most recent date (use start date) where the Treatment Plan is

linked.

Target Date – This is the objective date for the student to master the goal.

Target Observations - The ideal number of observations that should be collected for the goal.

Lessons – Indicates how many lessons that have been saved for the treatment goal.

Add Multiple Treatment Goals

Multiple treatment goals may be added at one time by clicking on the corresponding button when

viewing a treatment plan. Enter the target observations and target date if applicable and it will be set

on all goals that are added to the treatment plan. The lesson plans to be added may be filtered by:

The user that created the lesson plan

The lesson category

The lesson subcategory

Hold down the CTRL key to select multiple goals and then click the Add Goals button to add them to the

list. Once the goals have been added, a new filter and/or target values may be specified to add

additional goals. Finally click Save to save the goals on the plan. Note that if you do not click save, none

of the selected goals will be added to the treatment plan.

Treatment Goal Responses

The treatment goal responses show a summary of all response recorded for the corresponding lesson

plan. The data displayed is dependent upon the response type. A target value may be entered for each

treatment goal response (e.g. 80% correct). All the responses are listed when viewing the treatment

goal and contain summary information for the observations collected.

Baseline – This is the % correct average or average value (if numeric response type) for all

corresponding Lessons where the Treatment Plan is linked and Use as Baseline is checked on the

lesson.


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Current Level – This is the % Correct for the most recent (by start date/time) corresponding

Lesson where the Treatment Plan is linked.

Recalculating Treatment Goal Data

Typically, the data on a treatment goal will be automatically calculated as lessons and lesson

observations are entered into the application. However, there are instances where the treatment goals

may need to be “manually” recalculated. This may occur if a lesson is changed after the observations

are collected (e.g. use as baseline is checked, start date/time is changed). To recalculate the treatment

goals on the treatment plan simply click the Recalculate button found at the top of the treatment plan.

General Recommendations General Recommendations are used to add textual advice/suggestions for the student’s therapy to the

treatment plan that are beyond the scope of the existing fields on the plan. They contain two fields, a

subject and the recommendation itself. Multiple general recommendations may be added to the

treatment plan.

Therapy Recommendations Therapy Recommendations are used to add suggested procedure codes for the student’s therapy to the

treatment plan. Multiple therapy recommendations may be added to the treatment plan. They consist

of the following fields, however only the procedure is required to save the record.

Procedure – Select the advised procedure code for the student.

Hours Per Month – Enter the suggested hours per month that the student should receive the

therapy.

Expected Duration – Enter the number of months expected for the recommended procedure.

Comments – Enter any comments for this therapy recommendation.


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Examples

Lesson Categories/Plans Below is an example of how the lesson categories, subcategories and plans can be setup in your

practice.

Category: Social Skills

o Subcategory: Conversation Skills

Plan: Greeting

Plan: Taking turns talking

o Subcategory: Group Meetings

Plan: Initial Greeting

Plan: Choosing a seat

Category: Activities of Daily Living

o Subcategory: Showering/Bathing

Plan: Prepare shower

Plan: Test water

Category: Mathematics

o Subcategory: Addition

Plan: Add single digits

Plan: Add double digits

o Subcategory: Division

Plan: Division by 1

Plan: Division by 2

Plan: Division by 10


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Compact versus Expanded Layout The two images below show the difference between the compact and the expanded layout for a lesson

plan when performing the lesson. The lesson plan had a single yes/no response, four prompts and

included the protest section.

Compact

Expanded

Documents

TotalABA Clinical Documentationinviscidsoftware.com/trainingVids/Manuals/TotalABA... · plan templates. The following fields/sections are available on the template: Template Name